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2 The U.S. Department of Health and Human Services National Diabetes Education Program (NDEP) is jointly sponsored by the National Institutes of Health and the Centers for Disease Control and Prevention with the support of more than 200 partner organizations NDEP ( ) TTY: NIH Publication No NDEP-37 Last Reviewed February 2013

5 Executive Summary This guide is designed to help health care professionals and health care organizations implement collaborative, multidisciplinary team care for adults and children with diabetes in a variety of settings. Collaborative teams that provide continuous, supportive, and effective care for people with diabetes throughout the course of their disease are a model for the prevention and management of chronic diseases. Well-implemented diabetes team care can be cost-effective and the preferred method of care delivery, particularly when services include health promotion and disease prevention, in addition to intensive clinical management. Team care is a key component of health care reform initiatives that incorporate an integrated health care delivery system, especially those for chronic disease prevention and management. Diabetes is a serious, common, and costly disease that affects 29.1 million Americans, or 9.3 percent of the U.S. population. About 90 to 95 percent of people with diabetes have type 2, which usually occurs in adults over age 45 but is increasingly occurring in younger age groups. Type 1 is usually diagnosed during childhood, although adults can also develop the disease. Some patients may have features of both type 1 and type 2 diabetes, which further complicates disease treatment and management. In addition 86 million Americans aged 20 years or older have prediabetes, which places them at increased risk for cardiovascular disease and type 2 diabetes. The chronic complications of diabetes (cardiovascular disease, vision loss, kidney failure, nerve damage, and lower-extremity amputations) result in higher rates of disability, increased use of health care services, lost days from work, unemployment, decreased quality of life, and premature mortality. Acute complications can also result in lost days from school. The estimated diabetes cost in the United States in 2012 was $245 billion. Despite its multi-system effects, it is possible to prevent or delay the onset of type 2 diabetes as well as to effectively manage both type 1 and type 2. Unequivocal evidence shows that early detection and early and aggressive ongoing therapeutic intervention significantly reduces the enormous human and economic toll from diabetes. To achieve the health benefits that modern science has made possible, the principal clinical features 3 of diabetes hyperglycemia, dyslipidemia, and hypertension need to be prevented and managed within a system that provides continuous, proactive, planned, patientcentered, and population-based care. Primary care physicians, physician assistants, and nurse practitioners all play important roles in the delivery of primary care for people with chronic diseases in the United States. To reduce the risk of microvascular complications, this care needs to include regular assessment of the eyes, kidneys, teeth and mouth, and lower extremities in people with diabetes. System constraints, however, can make it difficult for primary care providers to carry out all of these essential elements of comprehensive diabetes care. The challenge is to broaden delivery of care by expanding the health care team to include several types of health care professionals. Team care can minimize patients health risks by assessment, intervention, and surveillance to identify problems early and initiate timely treatment. Increased use of effective behavioral interventions to lower the risk of diabetes and treatments to improve glycemic control and cardiovascular risk profiles can prevent or delay progression to kidney failure, vision loss, nerve damage, lower-extremity amputation, and cardiovascular disease. Patients participation in treatment decisions, personal selection of behavioral goals, patient education and training, and active self-management can improve diabetes control. This in turn leads to increased patient satisfaction with care, better quality of life, improved health outcomes, and ultimately, lower health care costs. Collaborative teams vary according to patients needs, patient load, organizational constraints, resources, clinical setting, geographic location, and professional skills. It is essential that a key person coordinate the team effort. The resources and support of community partners such as school nurses, community health workers, trained peer leaders, and others can augment clinical care teams. Non-traditional approaches to health care such as telehealth, shared medical appointments, and group education all expand access to team care and, if used effectively, can build team care practices. Redesigning the Health Care Team

6 The benefits of diabetes team care include efficient patient education, improved glycemic control, increased patient follow-up, higher patient satisfaction, lower risk for the complications of diabetes, improved quality of life, reduced hospitalizations, and decreased health care costs. It is difficult, however, to measure team care effects beyond these intermediate outcomes. Future evaluations of model medical home health care delivery programs will likely provide additional data about improved patient outcomes. Effective team care requires the commitment and support of organization leadership the active participation of the patient and health care professional team members ways to identify the patient population via an information tracking system adequate resources payment mechanisms for team care services a coordinated communication system documentation and evaluation of outcomes and adjustment of services as necessary Teams can work effectively in many varied settings to improve the quality and effectiveness of diabetes care. Payment of services provided by health care professionals other than primary care providers and specialists such as registered nurses, registered dietitians, and psychologists although improving, often is inadequate. Examples in this guide from the peer-reviewed literature and case studies show the diversity and effectiveness of health care professional teams working with people with diabetes. These include community-based primary care providers who involve a pharmacist and dietitian in implementing treatment algorithms, nurse and dietitian case managers, and educators who help to improve patients weight loss and A1C values a nurse practitioner-physician team that manages patients with diabetes and hypertension nurse and dietitian diabetes educators who help people with and at risk for diabetes achieve behaviorchange goals leading to better clinical outcomes and who work with primary care physicians and staff to provide diabetes day individual and group patient appointments school nurses who contribute to diabetes prevention and management in their students a nurse, social worker, or psychologist who works closely with older patients, their primary care physician, and a consulting psychiatrist to treat depression health care professionals who use telehealth to improve eye care, nutrition counseling, and diabetes self-management education pharmacists who work with company employees who have diabetes and their physicians to improve clinical measures and lower health care costs trained community-based fitness instructors who deliver group-based lifestyle interventions in YMCA settings to people at risk for diabetes to achieve increases in physical activity and significant weight loss trained community health workers who bridge the gap between traditional health care teams to improve access to diabetes health care, complications assessment, and education in underserved communities podiatrists and other health care professionals who help reduce lower-extremity amputation rates in foot care clinics dental and eye care professionals who help prevent and manage diabetes complications There is evidence that a team approach reduces risk factors for type 2 diabetes, can improve diabetes management, and can lower the risk for chronic diabetes complications. This evidence, in turn, shows that an opportunity exists for health care professionals and health organizations to improve the health of people with diabetes. It is important, however, that studies of team care interventions involving the skills of numerous health care professionals should continue to elucidate effective ways to implement team care to improve patients well-being and assess the costs involved. For Team Care-Related resources see page 37. 4

7 1. Introduction The problem Diabetes is a serious, common, and costly chronic disease that affects 29.1 million Americans, or 9.3 percent of the U.S. population. About 1.7 million new cases are diagnosed annually among adults aged 20 years or older.[1] Diabetes disproportionately affects African Americans, Hispanic Americans, American Indians, Asian and Pacific Islanders, and older Americans. Complications from the disease include cardiovascular disease, vision loss, kidney failure, nerve damage, and lower-extremity amputations. These complications can subsequently result in higher rates of disability, increases in the use of health care services, lost days from work, unemployment, illness, and premature death. Type 1 and type 2 diabetes Type 1 diabetes usually strikes children and young adults, although disease onset can occur at any age. In adults, type 1 diabetes accounts for 5 to 10 percent of all diagnosed cases of diabetes.[1] About 90 to 95 percent of people with diabetes have type 2 diabetes, which more commonly occurs in adults older than age 45 who are obese and have a family history of the disease. Overweight and obese children are at increased risk for developing type 2 diabetes during adolescence and later in life. This increased incidence of type 2 diabetes in youths is a first consequence of the obesity epidemic among young people and a significant and growing public health problem.[2] Intensive versus standard therapy Investigators in the Diabetes Control and Complications Trial (DCCT), a large clinical trial of intensive versus standard therapy for adults with type 1 diabetes, reported in 1993 that intensive glucose control reduced eye, nerve, and kidney damage. Findings reported in 2005 from the Epidemiology of Diabetes Interventions and Complications[3] (DCCT follow-up) study and in 2008 from the 10-year follow-up of the United Kingdom Prospective Diabetes Study (UKPDS)[4], show that intensive glucose control (A1C* goal <7 percent) in newly diagnosed people with either type of diabetes not only has benefits during the period of intensive therapy but also has a legacy effect in which micro- and macrovascular benefits are realized years later. Cost of diabetes The estimated diabetes cost in the United States in 2012 was $245 billion, including $176 billion for direct medical costs and $69 billion in indirect costs, such as disability, time lost from work, and premature death.[5]. Computer modeling has shown that compared to standard treatment, early, effective diabetes management can reduce treatment costs for diabetes complications of the eye, kidney, and extremities.[6] There is a marked correlation between glycemic control and the cost of medical care, with medical charges increasing significantly for every 1 percent increase in A1C above 7 percent.[7] The increase in medical charges accelerates as the A1C value increases. Prevention or delay of diabetes onset Eighty-six million American adults have prediabetes and are likely to develop type 2 diabetes within 10 years, unless they take steps to prevent or delay diabetes. Prediabetes occurs when a person s blood glucose is higher than normal but not high enough for a diagnosis of diabetes. The Diabetes Prevention Program (DPP), a large prevention study of people at high risk for diabetes, showed in 2002 that lifestyle intervention reduced the 5

8 incidence of diabetes by an average of 58 percent over 3 years (by 71 percent among adults age 60 or older); diabetes incidence was reduced by 31 percent in those taking metformin.[8] A cost-effectiveness model estimated in 2005 that the DPP lifestyle intervention would cost society about $8,800 per quality-adjusted life-year saved (within a typically acceptable range). Metformin would cost about $29,900 per quality-adjusted life-year saved and was considered not cost-effective after age 65.[9] In 2009, a 10-year follow-up of DPP participants, the Diabetes Prevention Program Outcomes Study, found that diabetes incidence was reduced by 34 percent in the lifestyle group and 18 percent in the metformin group compared with placebo. These results show that prevention or delay of diabetes with lifestyle intervention or metformin can persist for at least 10 years. [10] Interventions to prevent or delay type 2 diabetes in people with prediabetes are feasible and could be cost-effective. Models for better diabetes care The Chronic Care model,[11, 12] the Medical Home model,[13] and the Healthy Learner model[14] provide frameworks for effective care of diabetes and other chronic diseases. All incorporate team care as a vital component of delivery system design. These models will likely guide health care reform initiatives that incorporate an integrated health care delivery system. This publication, Redesigning the Health Care Team: Diabetes Prevention and Lifetime Management, provides the following an overview of the evidence that supports team care as a component of effective diabetes management practical information to help health care professionals and organizations incorporate team care into practice in a variety of settings steps for forming and maintaining a successful team eight case studies that demonstrate real-world team care in several different settings * NDEP and its partners have adopted the simple name A1C for the hemoglobin A1C test. A1C is a standardized blood test that indicates the average blood glucose over the previous 8 to 12 weeks. A1C values and self-monitoring of blood glucose can be used to guide therapy to achieve glycemic targets. People with diabetes need to know their own A1C values and whether they are reaching their targets. For Team Care-Related resources see page 37. Redesigning the Health Care Team 6

9 2. Chronic Disease and the Health Care Delivery System Health care environment Today s health care environment is affected by several significant factors, including greater numbers of aging and older people, the development of new technologies, advances in medical treatments, and the tremendous increase in scientific knowledge about health and illness. One result is that more people are living longer with diabetes and its complications. In spite of the growing diabetes population and the high cost of this disease, people with diabetes are often poorly served by the current health care system that is primarily symptom oriented and focused on acute illness. Additionally, payment is heavily weighted toward medical procedures or treatment of late complications of disease, rather than toward the cognitive and time-consuming efforts required for successful primary or secondary disease prevention. Current payment policies need modification to support team care for effective chronic disease management. Primary care providers Primary care physicians, physician assistants (PAs), and nurse practitioners (NPs) all play important roles in the delivery of primary care for people with chronic diseases in the United States. Although endocrinologists or other diabetes specialty physicians are involved in caring for many people with diabetes, primary care physicians provide more than 80 percent of diabetes care.[15] In the past, physician shortages in rural or other underserved communities were addressed in part by PAs and NPs. Currently, however, about 33 percent of PAs practice in primary care, 15 percent practice in rural areas, and 8 percent in federally qualified health centers and community health facilities.[16] The PA profession appears to be moving away from primary care toward specialty training to support specialty physician practices. [17] NPs have traditionally worked in primary care, and a recent national survey reported that the average NP was female (95 percent), 48 years old, in practice for 10.5 years, and a family NP (49 percent) involved in direct patient care.[18] Schools of nursing are increasing training programs for doctoral-level comprehensive care practitioners.[17] Systems constraints can make it difficult for primary care providers to carry out elements of comprehensive diabetes care, such as to identify a practice s sub-population of patients with diabetes and target those at highest risk for co-morbidities conduct ongoing self-management education and behavioral interventions provide remote management of glycemia promote risk-factor reduction and healthy lifestyles provide periodic examinations for early signs of complications[19] The challenge is to broaden the delivery of primary care by expanding the health care team to effectively address the various elements of comprehensive diabetes care. Models for care delivery The models briefly described on the next page share many similar elements. Each element, however, is a 7

10 complex undertaking, and the level of guidance available varies in its implementation and evaluation of effectiveness for improving chronic care. Chronic care model The chronic care model[11] presents six interrelated elements for effective care of chronic diseases: the health system culture, organizations, and mechanisms to promote safe, high-quality care delivery system design for clinical care and selfmanagement support, including team care decision support based on evidence and patients preferences clinical information systems to organize patient and population data self-management support to enable patients to manage their health and health care community involvement to mobilize patient resources In 2002, a systematic review included diabetes care programs that featured at least one of four chronic care model elements: delivery system design, decision support, clinical information systems, and self-management support.[20] This review found that 32 of 39 programs improved at least one process measure (e.g., testing A1C) or one outcome measure (e.g., lowering A1C) for patients with diabetes by implementing at least one of the four chronic care model elements. Since the methodological quality of the studies was not uniformly high and the interventions differed among studies, the review authors cautioned about generalizing these findings. In 2005, a meta-analysis[21] was conducted of randomized and non-randomized controlled trials in chronic disease that addressed one or more elements of the chronic care model. Diabetes was one of the four chronic diseases studied. This analysis found that interventions that incorporated at least one element of the model had consistently beneficial effects on process and outcome measures across the four diseases. Interventions for diabetes led to a percent reduction in A1C but no measurable benefit in quality of life. The elements responsible for these benefits could not be determined from the data. Medical home model The American Academy of Pediatrics originally used the term medical home to describe a partnership approach to providing family-centered, comprehensive health care.[22] The model has since been embraced by the major U.S. primary care organizations, other health care provider groups, private health care purchasers, labor unions, and consumer organizations. This evolving model of care is playing an important part in health care reform. [23] Also known by other names such as the Advanced Primary Care model, the medical home links multiple points of health delivery by utilizing a team approach with the patient at the center. The model emphasizes prevention, health information technology, coordination of care, and shared decision making among patients and their health care team.[24] Nurses, diabetes educators, dietitians, pharmacists, podiatrists, eye care providers, dental professionals, and other health care professionals are likely to play important roles in the medical home model by working with primary care providers to collaboratively provide comprehensive diabetes care. Such care includes management of blood glucose, lipids, and blood pressure; weight management; smoking cessation counseling; and diabetes complication care and prevention. Implementation of the medical home model will require modification of current health care provider payment policies to support team care.[25] Medical home demonstration projects for Medicare beneficiaries are planned for community health centers across the country and for primary care practices in eight states. Medicare may join Medicaid and private insurers to conduct state-based primary care initiatives. These projects will incorporate payment modification for team care and evaluate the effectiveness of the model in improving health care quality and reducing costs.[24] Their findings will help guide future efforts to integrate and disseminate the model s key components, including payment mechanisms into other settings.[13] Healthy learner model The Healthy Learner Model extends the Chronic Care Model to include professional school nurses in chronic disease management for students in kindergarten through grade 12.[14] This model enables improved communication and coordination among health care professionals, students with chronic diseases and their families, and school personnel. The goal is to maintain student health in the school setting. Leadership involving communities and school districts is critical to the model as is evaluation of success in maintaining student health. The Healthy Learner Model has been successfully implemented and evaluated in Minneapolis Public Schools and St. Paul Public Schools to improve the health of children with asthma.[26] The model needs further application to diabetes and replication in other school districts. 8

11 3. What Makes a Successful Team? Integral role of the patient and family Team care integrates the skills of primary care providers and other health care professionals with those of the patient and family members into a comprehensive lifetime diabetes management program[19, 27] that is of high quality and is cost-neutral[28] or cost-effective. [29] The patient is the central team member, since most diabetes care is carried out by the person with diabetes or his or her family. Patients need to understand their roles as self-care managers and decision-makers to effectively work with members of their health care team. Family members assume most of this role for children and teens with diabetes. Health care professionals Teams usually include health care professionals with complementary skills who are committed to a common goal and approach.[30] Some health care professionals may choose to become certified diabetes educators (CDEs). (See Appendix 2 for information on the role of CDEs.) Team composition varies according to patients needs, patient load, organizational constraints, resources, clinical setting, geographic location, and professional skills. [31] It is essential that a key person coordinate the team effort. Non-traditional approaches to health care such as telehealth, shared medical appointments, and group education all expand access to team care. What can team care accomplish? Many examples of team management for people with diabetes can be found in the scientific literature. A 2006 meta-analysis assessed the impact on glycemic control of 11 distinct strategies for quality improvement in adults with type 2 diabetes.[32] Across 66 trials (50 randomized, three quazi-randomized, and 13 controlled beforeafter trials), two of 11 categories of quality improvement strategies were associated with reductions in A1C values of at least 0.5 percent. The two categories were team changes and case management. Effective team changes included the use of multidisciplinary teams, shared care between specialists A flexible plan helps meet specific needs Not every team member needs to be involved in every patient s care. A flexible plan helps determine the most effective team, as needs will change over time. For example A podiatrist may be involved in care for people with neuropathy, ulcerations, and other foot pathology. Podiatrists can provide comprehensive annual diabetes foot care examinations. A pharmacist may assist patients with multiple co-morbidities, or those requiring polypharmacy. Nurse educators, diabetes educators, and case managers can provide initial and ongoing diabetes self-management education, diabetes management support, and medication management services. Eye care professionals (optometrists and ophthalmologists) can provide comprehensive eye and vision care, including an annual dilated eye exam. A psychologist or social worker may be part of a team providing child and adolescent care. Dental professionals conduct oral examinations and provide oral health education in some community health centers. Clinical care teams can be augmented by the support and resources of school nurses, home health nurses, community health workers, and other community partners. and primary care physicians, or adding a new team member with an expanded professional role. Effective case management involved nurse or pharmacist case managers who followed physician-supervised algorithms to make medication adjustments. Similar results were found in a group of low-income Latino patients who received supervised, nurse-directed care using detailed treatment algorithms.[33] Multidisciplinary teams are involved in pediatric care to effectively manage youths with diabetes.[34, 35] Team care contributed to the Steno-2 Study[36], a target-driven, long-term, intensified intervention that significantly 9

12 reduced the risk of cardiovascular disease and microvascular events in adults with type 2 diabetes and microalbuminuria.[37] Although team care may have played a role in the success of other large clinical trials, there is little discussion of its contribution in the literature. Possible Diabetes Team Care Outcomes Studies of diabetes team care in a variety of settings (see section 6) have shown improvements in one or more of the following glycemic, lipid, and blood pressure control patient follow-up patient satisfaction risk for diabetes complications quality of life health care costs Six Team-building Steps These six steps identify important considerations for those creating or expanding team care, regardless of setting or program size. 1. Ensure the commitment of leadership The first step requires care providers and other key decision-makers to commit to the implementation of multidisciplinary team care and the necessary resources and infrastructure to enable the team to function. A planning group can then carry out the next steps. Select well-respected clinicians to serve as catalysts to generate interest and support among colleagues. Meet with primary care providers and other potential team members, policy makers, and payment specialists such as business or office managers to obtain their support. Involve core team members early in organizational and clinical decision-making to gain their active participation. Demonstrate team care on a small scale, if necessary, to assess its feasibility, effectiveness, and impact. 2. Identify team members Invite potential team members to commit to participation. How to build and maintain effective teams Six Team-building Steps presents important considerations for those creating or expanding team care, regardless of setting or program size: commitment of leadership; contributing team members; an identifiable patient population; adequate resources; a system for coordinated, continuous high-quality care; and an effectiveness evaluation plan. Five Steps to Maintain a Successful Team presents elements that ongoing successful teams can promote: team coordination and communication; patient satisfaction, quality of life, and self-management; a community support network; patient follow-up; and the use of secure computerized clinical information systems. Clarify the roles of team members to resolve issues related to leadership and role overlap or redundancy in the care delivery process.[38] Ensure mutual respect and a common vision. 3. Identify the patient population Initial assessment may be limited to general demographic characteristics and an estimate of the proportion of patients with type 1, type 2, and gestational diabetes. Further assessment could determine the presence of risk factors, number of patients with and without diabetes complications, severity of complications, the extent of comorbidities, use of health services, and delivery of preventive care.[39] 10

13 Once the diabetes patient population is known, the team might want to stratify the population into groups according to the intensity of services required. Newly diagnosed patients with limited diabetes complications might benefit from relatively low-cost preventive care focused on risk factor reduction and health promotion. Patients with diabetes complications or other comorbidities over the previous two-year period might need more intensive management with more extensive resources (see Appendix 1, Stratifying Team Care According to Patient Population Needs). 4. Assess resources Identify strengths and weaknesses in available resources (such as support staff, education materials, equipment, supplies, home care services, support groups, follow-up services, community resources). Ensure that adequate space, equipment, and supplies are available. Determine payment mechanisms for health care professional services, equipment, and supplies. Assemble user-friendly, current diabetes prevention and management protocols, tools, and education materials to ensure the delivery of current, culturally sensitive, and consistent care. These include standards of care, treatment guidelines, protocols and algorithms, patient education materials, flowcharts, standing orders, chart stickers, and other recording and reminder systems (see various resources in Resources section). 5. Develop a system for coordinated, continuous, high-quality care Define the team philosophy, goals, and objectives. Develop a secure information system for patient identification, data collection, ongoing assessment, and monitoring the achievement of specific clinical performance measures such as hemoglobin A1C, blood pressure, and lipid target values, as well as patient satisfaction and quality-of-life indicators. Determine the structure and scope of the program or service. Teams can provide medical and clinical care; diabetes risk-reduction counseling; diabetes, lipid, and hypertension management; self-management education and medical nutrition therapy; psychosocial counseling; complications risk-factor reduction counseling; screening for complications; followup care; coordination of referrals to specialists; and access to supportive clinical and community resources. Base care on evidence-based guidelines adapted from widely accepted standards or practice guidelines to meet local conditions.[40] (See various resources in Resources section.) Develop a system that supports continuity of care through regular team meetings and ongoing documentation and communication of pertinent information among team members, ideally via a computerized information system. Structure a payment system for professional services (see Resources AADE, ADietA, CMS). 6. Evaluate outcomes and adjust as necessary Periodic process and outcome evaluations can help to improve team function and patient care. Databases with analytic reports, pooled medical record audit findings, utilization data (such as hospital length-of-stay, emergency room visits, and total dollars spent) can help evaluate outcomes of team care, determine future progress, and indicate team success in meeting quality measures (see Appendix 3, Quality Improvement Indicators for Diabetes Care). Patient satisfaction and quality-of-life interviews or questionnaires for patients can provide valuable feedback to the team and may influence the scope and manner of care provided. Document clinical, behavioral, and financial outcomes to show payers and other stakeholders the value of the services and return on investment. If desired, teams could seek funding and resources from a nearby university or other facility for an evaluation expert for advice or to conduct a more formal program evaluation. 11

14 Five Steps to Maintain a Successful Team Regardless of the team structure and purpose, several important elements need attention for ongoing, successful team care. These elements are presented below in no particular order. 1. Promote patient satisfaction, quality of life, and self-management Address patients concerns such as insurance coverage and billing, confidentiality, time spent waiting, accessibility of providers, and continuity of care, to improve patient satisfaction. Provide self-management education to equip patients with the knowledge and skills to actively participate in their care, make informed decisions, set collaborative goals, carry out daily management, evaluate treatment outcomes, and communicate effectively with the health care team. Reassess and redefine collaborative goals and supportive care to sustain achievement of goals over time. 2. Promote a community support network The support of family, friends, and the entire community can help people with diabetes sustain self-management practices and a positive outlook over time. Assess community support and resources such as institutional funding and grants from community agencies, groups, or services. Grants or industry support for indigent programs may be available. Determine available Medicare and other insurer payment for health care professional provider services (including diabetes patient education and nutrition counseling), equipment, and supplies (see CMS Resources). Help people with diabetes develop a community support network that includes family, friends, support groups, the faith community, and needed services such as transportation. Encourage community organizations to support routine physical activity and the concept of healthy foods for all to create an environment that can contribute to improved health outcomes and quality of life. 3. Maintain team coordination and communication Develop clear procedures to facilitate timely coordination of all required services. Consider using standard treatment algorithms (see various items in Resources). Reassess periodically to ensure continuity of care and patient satisfaction. Develop communication methods between team members and the patient such as team meetings, patient rounds, and journal clubs to promote cohesion and a common approach to patient care. Set individual patient clinical targets for blood glucose and lipid values, A1C, blood pressure, and body weight, and behavioral targets for food intake and physical activity. These targets provide a common ground for discussion of management strategies, collaborative goals, and evaluation of treatment outcomes. Develop and maintain consistent messages from all team members to enhance patient understanding and increase effective self-management behaviors. Communicate and document pertinent information from team members, ideally via a computerized information system. Encourage mutual respect between team members and the patient. A multidisciplinary planning and documentation tool for the medical record could include treatment goals, personal patient goals, and disease management including medications, medical nutrition therapy, self-management education, and referrals. Such a tool can help all team members to clarify responsibilities, coordinate care, and communicate the patient s progress in a timely way.[38] 12

15 Referral reports from eye care, foot care, dental professionals, and others can be incorporated into the patient s health record through computer-generated reports, medical record notes, and personal and telephone contact. (See NDEP Resources for a microvascular checklist.) 4. Provide follow-up Ongoing patient follow-up and regular scheduled visits for diabetes education, support, management, and preventive care are important to team success. A system to monitor and recall individuals for treatment and appointments, planned visits, and ongoing collaborative goal setting will facilitate the provision of these services. Essential preventive services include foot examinations; screening for microalbuminuria, visual acuity, and glaucoma; retinal eye examinations; and oral screening and preventive dental care. Follow-up care can be in the form of return face-toface visits or interaction with other team members and community partners as well as telephone interviews and fax or correspondence. Sending patients reminders and questionnaires encourages appointment keeping. Arranging for patients to send self-monitored data and to receive phone counseling and ongoing therapeutic management can reduce the need for multiple clinic or office visits, prevent adverse events, and increase access to care for patients in medically underserved locations.[41-43] 5. Use health information technology Secure computerized clinical information systems can identify patients with diabetes, centralize their data and laboratory values, suggest a change in medication dosage, and enable timely referrals to other providers or specialists automatically remind the team to conduct selfmanagement education, provide preventive services, and schedule follow-up visits help monitor quality of care by pooling medical record audit findings and comparing them with baseline measures or values attained in other practice settings collect and report outcomes 13

16 4. Non-traditional Team Care Approaches Telehealth Team care without walls Telehealth applications Telehealth (or telemedicine) is the use of secure highspeed Internet connections for real-time video conferencing for medical, diagnostic, monitoring, and therapeutic purposes when distance and/or time separates the participants. Telehealth can expand access to health care and education for patients and health care professionals in remote rural and medically underserved locations, as well as increase the delivery of evidenced-based medicine and improve the consistency of care. Telehealth applications that expand the reach of the diabetes team include primary care digital retinal imaging for diabetes eye screening to augment or enhance regular comprehensive vision and eye health exams video conferencing for provider education (such as Brown Bag conferences) video conferencing for group diabetes education and individual counseling individualized telehealth for medical nutrition counseling (covered by Medicare) remote monitoring of self tests for blood glucose and blood pressure pediatric care for youth with type 1 diabetes in remote areas[44] shared web-based clinical information connecting the patient, endocrinologist, primary care provider, pediatric care experts, other specialists, and other team members secure and remote management web-based patient surveys and information libraries customized patient portals or personal health records hospital grand rounds education sessions (See Case Studies 1 and 2 that address telehealth.) Ocular telehealth programs These programs can deliver eye care in the form of retinal screenings to those with limited care access and may in some cases improve care for those with regularly available vision and eye health care. Validated telemedicine programs using remote digital imaging systems are able to detect diabetic retinopathy but may not adequately detect other ocular co-morbidities associated with diabetes, including refractive errors, glaucoma, cataracts, dry eye, nerve palsies, and iris neovascularization. Retinal images are examined remotely by trained professionals. The Indian Health Service (IHS)-Joslin Vision Network Teleophthalmology Program uses telemedicine technology to provide annual eye exams to American Indians and Alaska Natives with diabetes who live far from health care centers. A digital camera transmits photographs of a patient s eye to a central reading center, where IHS eye doctors interpret the images and send a report to the patient and primary care physician. The report includes the level of diabetic retinopathy, the presence of any non-diabetic retinal disease, and a recommended course of treatment. A four-year study showed that the program resulted in 50 percent increase in annual eye exams 51 percent increase in laser treatments to prevent blindness lower cost with quality equal to or better than a traditional dilated eye exam (See IHS resources.) Designing, building, and implementing an ocular telehealth program for diabetic retinopathy requires a clearly defined mission, goals (e.g., to preserve vision, reduce vision loss, and provide better access to limited forms of eye care), and guiding principles. When possible, these goals should be consistent with using telehealth to augment or enhance existing comprehensive eye care services. (See Resources under American Optometric Association and the Ocular Telehealth for two key documents that help an organization develop an effective and sustainable program.) Early detection through annual screening and treatment of diabetic retinopathy can reduce vision loss by 90 percent.[45] Remote assessment of diabetic retinopathy using telemedicine is an accurate and potentially low-cost way to identify retinal lesions and facilitate appropriate and timely use of specialty care. Future studies will hopefully provide cost-effectiveness data of this service. 14

17 Case Study 1: Telehealth Enhances Diabetes Team Care in Hawaii Joe Humphry, M.D. Setting Ms. LK is a 54-year-old Hawaiian female living on the Hamakua Coast on the Island of Hawaii with her husband and daughter. She has had type 2 diabetes for 10 years and associated hypertension and hyperlipidemia. She is under the care of a primary care physician at the rural community health center, which is about 10 miles from her home. Team members Team members include the patient and her family, primary care physician, eye specialist, chronic care nurse, community health worker, librarian, endocrinologist, and pharmacist. Services provided at the Community Health Center Ms. LK received her annual retinal screening using the teleophthalmology non-mydriatic camera at the health center. She previously had limited access to eye care. The retinal images were read by the Hawaii Telephthalmology Imaging Center, and the report was electronically sent to her primary care physician. Ms. LK received education about insulin use and administration, and hypoglycemia management from the chronic care nurse when insulin therapy became necessary. Services provided by the Native Hawaiian Health System To help manage her diabetes, Ms. LK enrolled in the Native Hawaiian Health System remote monitoring program. As part of the program, a community health worker visited Ms. LK at home and delivered a blue tooth-enabled blood glucose (BG) meter and blood pressure (BP) cuff for BG and BP monitoring, demonstrated how to transmit the BG and BP readings after each reading, and uploaded the BG readings to the web-based Chronic Disease Management Program. Shortly after the upload, Ms. LK received a text message from her health care team thanking her for enrolling in the monitoring program. The community health worker referred Ms. LK and her daughter to the local public library for training to access her online portal and view her personal health record. The program donated a computer to the library in exchange for the librarian training of patients and patients use of the computer. Other aspects of the Chronic Disease Management Program include an educational library, patient alerts, consultation, nutritional survey and assessment, behavioral health risk survey, electronic health record interface with the community health center, remote home monitoring, and a complete care plan. The program also conducts medication reconciliation to ensure that the patient is taking only currently prescribed medications and dosages. Communication The secure web-based Chronic Disease Management Program enabled the patient and the community health worker to communicate with the community health center physician and chronic care nurse. Ms. LK uploaded BG and BP readings for their review and received their instructions for adjusting her medication doses. The community health worker recorded the findings of her patient visits for the community health center physician and chronic care nurse to review and to convey further instructions as necessary. The patient and other team members also conducted secure consultations with an endocrinologist located on the Island of Oahu. The community pharmacist who refilled Ms. LK s medications was able to help her understand why she needed insulin. Insurance coverage In the current traditional payment system, the e-health activities and the outreach worker s time are not covered. The Community Health Center and the Native Hawaiian Healthcare System are compensated for enabling services, making the e-health system a covered service. In the future, coverage will be through the management fee for the Medical Home Model or covered through an Accountable Care Organization Model* with a single payment to a larger organization that has an integrated delivery system. Kaiser Permanente currently uses many of the components of this system to reduce cost and improve access. Outcomes Ms. LK s insulin was effectively adjusted, and she took her BP medication daily. Her improved BG and BP values were recognized by the web application, and she received supportive text messages recognizing her improved diabetes management. The community health worker visited her every two weeks. Ms. LK visited the community health center physician and chronic care nurse every three months. Between visits, they were in touch via . As a result of the telehealth support, face-to-face visit time focused on reviewing and setting self-management goals and discussing the support she needed to achieve her goals. Ms. LK took more responsibility for her diabetes self-management. Her selfmonitored BG, A1C, and BP values improved. *The Accountable Care Organization Model encourages physicians and hospitals to integrate care by holding them jointly responsible for Medicare quality and costs. 15

18 Other telehealth programs These programs provide a sample of possible uses of telehealth to expand the team care concept. The Arizona Diabetes Virtual Center of Excellence (ADVICE) is a comprehensive program for diabetes prevention, assessment, and management, carried out via Arizona Telemedicine Program Network.[46] The ADVICE program primarily provides diabetes education and individual telenutrition consultations in Spanish and English for Hispanics and American Indians who have inadequate access to health care. Case Study 2: Florida Initiative in Telehealth and Education for Children with Diabetes Toree Malasanos, M.D. This program was administered by the Florida Department of Health, Children s Medical Services Network (CMSN), to integrate telemedicine clinical care, web-based education for children with diabetes, and virtual home-based behavioral modification. The program has served about 99 children and their families (44 with diabetes and 55 with other endocrine disorders) in Volusia and Flagler Counties since Targeted telemedicine patients were characterized by low socioeconomic status, inadequate health insurance, poor access to care, poor understanding of the diabetes disease process, transient lifestyles, residence in an area without access to a pediatric endocrinology specialist, and overall low health literacy. The program addressed several problems encountered in the pediatric endocrine and diabetes clinic: poor access to care for children with chronic health care needs in remote locations poor payment and minimal time for diabetes education high use of urgent care for recurrent problems rather than home management poor diabetes management and a high hospitalization rate Services: Telemedicine clinical care Patients were seen initially and then annually in person by the pediatric endocrinologist located in Gainesville, at the University of Florida. A teleconference clinic was held bi-weekly for an average of 12 families per session. Nurses in the remote clinic downloaded meter data, obtained a focused history, made basic physical observations, and transmitted the information to the endocrinologist in Gainesville. The pediatric endocrinologist then participated in patient interviews and examinations via The Indian Health Service is expanding its use of telemedicine to bring primary care and specialty medicine to remote locations to reduce geographic barriers between remote, smaller communities and health care professionals (see IHS resources). Veterans Rural Health Resource Centers, opened by the Department of Veterans Health Administration in Vermont, Iowa, and Utah, are finding out how best to extend telehealth services to veterans living in rural areas (see Veterans Affairs Resources). real-time teleconferencing. Families were educated during the telemedicine visits and by the website about sick-day management and reasons to call the health care team. Families were supported in diabetes self-care by 24-hour telephone access to the endocrine team in Gainesville. Initial patient education was provided by a combination of hands-on education in Gainesville and the web education program. New guardians, families, teachers, and school nurses were invited to participate in the web education program, called Brainfood. Services: Home-based behavior change This statewide home-based virtual program replaced a model residential hospital unit with more than 20 years experience treating adolescents who had poor adherence, frequent hospitalizations, and impaired family dynamics. Families involved in the home-based program received three to five provider-initiated calls per week to encourage good diabetes self-management by addressing their individual barriers to care. Keys to the success of this program were a carefully designed curriculum based on the former residential program and provision of providerinitiated rather than family-initiated calls. Web-based diabetes education (Brainfood) This was an animated, multiple-literacy presentation of diabetes information (including material for nonreaders), with pre- and post-testing. Children with newly diagnosed diabetes were given abbreviated in-person education at the University of Florida, which was then supplemented with Brainfood. Currently, this program is available at It has been shown to increase knowledge about diabetes and its management. Team members Children with diabetes and their families worked as a team with the CMSN registered nurses, the pediatric endocrinologist, University of Florida registered nurses, a social worker and a nutritionist based at the remote clinic, and school nurses. A psychologist was part of the team for the home-based care. Continued on next page. 16

19 Florida has a state-funded telehealth program that provides diabetes care to pediatric patients who live in Daytona Beach and the surrounding areas and are insured through state and federal programs. At the time of a clinic visit, an on-site registered nurse obtains a standardized patient history, downloads the patient s blood glucose meter data, and faxes the information to the University of Florida, Gainesville, pediatric team. The nurse also arranges appointments with other providers such as a dietitian, a psychologist, or an ophthalmologist (see Case Study 2). Case Study 2: Florida Initiative in Telehealth and Education for Children with Diabetes Continued from page Payment for services The program was funded by a contract with the Florida Department of Health, CMSN. Medicaid granted a waiver for limited coverage of telemedicine services for children with special health care needs in under-served regions of Florida. A contract between the University of Florida and the CMSN provided funds for data management and research, unreimbursed medical costs including physician time, phone management for blood glucose control between visits, and the home-based behaviorchange program. This program was limited to CMSN and Medicaid clients; however, in states in which reimbursement for telemedicine services is allowed, private insurers typically follow the same pattern. (Medicaid reimbursement by state is described at ufl.edu/documents/telemedicine in Medicaid and Title V Report.pdf.) Outcomes Hospitalizations and urgent care utilization: For the three years before inception of the program, there were on average, 13 hospitalizations per year (47 days) for the total group, which subsequently decreased by 88 percent to 3.5 hospitalizations per year (5.5 days) over the two years this was formally evaluated. Emergency department visits for the total group decreased from 8 per year to 2.5 per year. On numerous occasions, ketosis was managed by telephone intervention alone, relying on familyinitiated calls. Clinical measures: The mean interval between appointments was reduced from 149 days before the program began to days over the two years this was formally evaluated. Of the children who had an A1C > 8 percent when they entered the program, the A1C dropped from a mean of 9.63 percent to 8.94 percent, p =.02. Of the children who had an A1C less than 8 percent at their entry into the program, 100 percent stayed below 8 percent. After two years, the average A1C for all the children was 8.79 percent. Nineteen of 23 children received the recommended annual dilated eye examination. Costs: Even when line charges and equipment of $18,826 were included, this program saved $27,860 per year, by reducing hospital days ($44,419/year) and emergency department visits ($2,267/year). This does not include transportation costs and work/school time saved. An additional savings of $64,978 could be considered if Medicaid transportation costs were included in the absence of the telemedicine clinic. Satisfaction with the telemedicine clinic: A survey of the 99 program patients (diabetes, 44; other endocrine disorders, 55) and their parents found high levels of satisfaction with the program. Related references Bell JA, Patel B, Malasanos T: Knowledge improvement with web-based diabetes education program: Brainfood. Diabetes Technol Ther 2006; 8(4): Adkins JW, Storch EA, Lewin AB, et al.: Home-based behavioral health intervention: Use of a telehealth model to address poor adherence to type-1 diabetes medical regimens. Telemed J E Health 2006; 12(3): Malasanos TH, Patel BD, Klein J, et al.: School nurse, family, and provider connectivity in the FITE diabetes project. Telemed Telecare 2005;11 Suppl 1:76 8. Malasanos TH, Burlingame JB, Youngblade L, et al.: Improved access to subspecialist diabetes care by telemedicine: cost savings and care measures in the first two years of the FITE diabetes project. J Telemed Telecare 2005;11 Suppl 1:74 6.

20 Shared medical appointments and group education A method to increase practice efficiency is shared medical appointments, where a multi-disciplinary team sees a group of patients. This model of care is a response to factors that include the increasing prevalence of chronic diseases such as obesity and diabetes, an aging population with a greater number of complex needs, the need to include family members in disease management and education, and limitations of the short traditional office visit.[47] Structure and setting Usually eight to ten patients participate every three months in a one- to two-hour appointment, although 20 or more patients can be seen in longer sessions.[48] Successful shared medical appointments for people with diabetes have been reported in various settings: health maintenance organizations[47, 49] a Veterans Health Administration (VHA) primary care clinic at a tertiary care academic medical center[48] a hospital-based secondary care diabetes unit[50] an adult primary care center serving uninsured or inadequately insured patients[51] Interventions Interventions usually focus on diabetes self-management support. Time is included for patients to meet individually with the primary care provider for evaluation of new medical problems, medication adjustments, and yearly checks for complications. Teams usually include two or more health care professionals, as needed, such as a family physician, clinical nurse specialist, nurse educator, NP, pharmacist, clinical health psychologist, dietitian, and podiatrist. Some of the health care professionals are certified diabetes educators (CDEs). Other care providers, such as eye specialists and dental professionals, could also be included. (See Appendix 2 for information on the role of CDEs.) A meta-analysis of randomized controlled and controlled clinical studies of group education programs for adults with type 2 diabetes was compared with routine care, wait list control, or no intervention.[52] Studies were included if the intervention was at least one session with a minimum of six participants and if the length of followup was at least six months. Fourteen publications describing 11 studies that involved 1,532 participants were included. The analysis found significant improvements in fasting blood glucose levels and A1C self-care knowledge systolic blood pressure levels body weight Diabetes medication dosage was reduced in one out of five participants.[52] Other studies of group visits report fewer hospitalizations and emergency room visits[47, 49] improved quality of life[50] increased patient satisfaction[47] lowered cardiovascular risk [48] weight loss, smoking cessation, increased physical activity, and improved depression scores[53] (See Case Study 3 on group visits.) Evaluation Success of the group visit model depends on skilled use of social and facilitation techniques by the health care team identification and scheduling of appropriate patients using a patient registry interpersonal sharing between patients training support staff active participation by all stakeholders[47] 18

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